Pregnancy is a period in which there are important biological and psychosocial changes in woman’s life and where the risk for experiencing many factors that can create anxiety and stress is high (1). During pregnancy, while exacerbation in existing psychiatric symptoms can be seen, psychiatric symptoms encountered for the first time may also occur (2).
In studies conducted in our country, prevalence of depressive symptoms during pregnancy was reported to be between 27.3% and 36.3% (3). While 10% of the pregnant women met criteria for unipolar depression, increased depressive symptoms were seen in 18% (4). However, in pregnancy and postpartum period, only 18% of women, who meet the criteria for unipolar depression is admitted for treatment (4). Clinically significant anxiety disorders have been identified in 60% of women in prenatal period and in 70% of women in postnatal period (5).
During pregnancy, prevalence of bipolar disorder and psychotic disorders are not known exactly (6). In prospective studies which female patients with bipolar disorder were followed throughout their pregnancy, it has been shown that 70% of these women have at least one mood episode and ratio of having new episode raised to %85-100 in women who stopped taking their mood-stabilizers (7). Nearly half of pregnancies in patients with schizophrenia are unwanted and unplanned and discontinuation of medicaments also increases the risk of relapse (8).
Psychiatric disorders that are not treated adequately in pregnancy period lead to maternal malnutrition, decreased prenatal medical care, smoking, alcohol and other substance abuse, self-destructive behaviors and increase in obstetric complications (9,10). In fetal period, this situation may cause baby’s exposure to the harmful effects of the disorders and in postpartum period it may cause some unwanted short and long term consequences by effecting the interaction and binding between mother and baby (9,10).
In this study, clinical and sociodemographic data of pregnant patients, who were hospitalized in our clinic between 2004-2012, their follow-up results and potential effects of psychiatric disorders on newborns and course of pregnancy were investigated.
In this study, clinical and sociodemographic data of 68 pregnant women, who were treated as in-patient for a psychiatric disorder in the Department of Psychiatry of Gaziantep University Faculty of Medicine between 2004-2012 were analyzed retrospectively. Sociodemographic data, complaints, personal and family history characteristics, mental status examination, Axis I diagnoses according to the DSM-IV-TR criteria, applied scales and laboratory information of patients were obtained from the archived files in the clinic and the hospital. Information of patients such as duration of birth, mode of delivery and the baby’s health condition was recorded via phone calls. The study was approved by the Medical Ethics Committee of Gaziantep University Faculty of Medicine. Data were analyzed with SPSS 18.0 software, descriptive analysis was performed and results were expressed as percentages.
Of the 68 patients enrolled in the study, 43 patients (63.3%) had unipolar depression, 20 patients (29.4%) had bipolar disorder, 3 patients (4.4%) had obsessive-compulsive disorder (OCD) and 2 patients (2.9%) had schizophrenia. The mean age of the patients was 29.6±5.1 (range between 18 and 43). While 23.5% of the patients (n=16) had a diagnosis of psychiatric disorder for the first time during their pregnancy, 76.5% of them (n=52) had already a psychiatric disorder prior to pregnancy. Electroconvulsive therapy (ECT) was used alone in 33.8% of the patients (n=23); 36.8% of the patients (n=25) were given only drug treatment and 29.4% (n=20) of the patients were treated both with the medication and ECT. Some of the socio-demographic and clinical data of the patients are shown in Table 1.
37.2% of the patients (n=16) with unipolar depression were treated with ECT alone, 39.5% of the patients (n=17) were only treated with drugs and in 23.2% (n=10) of the patients ECT and drug therapy were administered together. Preterm birth was not detected in 26 women, whose birth information were accessed. While there were not any medical problems in 30 infants, whose postpartum information were available, 13 infants’ postpartum period information were not obtained. Given the clinical global impression-severity (CGI-S) score of ≤2 and the Hamilton Depression Scale (Ham-D) score <7 is considered to be complete treatment response, 93% of patients with unipolar depression in our study have fully benefited from treatments applied. The reason for the high treatment response in patients with unipolar depression may be that 60.5% of them were treated with ECT alone or ECT and medication together.
Of the patients treated with a diagnosis of bipolar disorder, 10 (50%) were in manic episode, 5 (25%) were in depressive episode and 5 (25%) were in mixed episode. While recurrence was seen in14 patients (70%), 6 of them (30%) were diagnosed for the first time. 30% of patients (n=6) were treated only with ECT, 45% (n=9) were treated with ECT and drug treatment and 25% (n=5) were treated with drugs alone. Treatment with mood stabilizers had been discontinued due to pregnancy. While there was not any medical problem in 16 of 17 infants whose postpartum information is available, a cardiac disease was detected in an infant who has healed with treatment for 3 months. Postpartum information of 3 infants was not available. 70% of patients with bipolar disorder have benefited from treatments applied.
One of the patients with schizophrenia was treated with ECT alone whereas the other was treated with ECT and drug together. There were not any medical problems in both of the infants whose postpartum information were available.
However, patients with OCD have benefited partially. While there was not any medical problem in 2 of 3 infants, congenital hip dislocation were identified in one of them.
Test values of the scales administered to patients before and after treatment were demonstrated in Table 2. Of the patients with unipolar depression, 9 of them were given sertralin, 6 of them were given fluoxetine, 2 of them were given escitalopram, 1 of them was given paroxetine, 4 of them were given clonazepam and 1 of them was given lorazepam treatment during pregnancy. Of the patients with bipolar disorder, 4 of them were given amisulpride, 3 of them were given olanzapine, 2 of them were given haloperidol, 1 of them was given risperidone and 3 of them were given clonazepam treatment. Among the schizophrenia patients, one of them was given amisulpride. 2 of the patients with OCD were given fluoxetine and 1 of them was given citalopram.
In a naturalistic prospective study, which investigated women with unipolar depressive disorder who became pregnant in euthymic period, it has been shown that unipolar depression relapsed in 43% of patients during pregnancy (11). In our study, the diagnosis of unipolar depression was present before pregnancy in 76.7% of patients, who also had the diagnosis of unipolar depression during pregnancy. 23.3% of patients with unipolar depression have got the diagnosis for the first time.
In a study which compared the course of bipolar disorder in patients whom had given up taking mood stabilizers early in pregnancy or before pregnancy with those who continued taking their treatment, the risk of recurrence was found to be 71% throughout pregnancy period (12). In our study, 70% of patients with bipolar disorder had psychiatric diagnosis before pregnancy.
Although there is limited data on schizophrenia during pregnancy, it has been reported that patients, who stopped treatment have 2-3 fold increased risk of becoming ill compared to the patients, who continued their tratment (8). In a study which OCD patients were examined during pregnancy, it has been shown that 34.1% of patients had exacerbation and 22% of them had improvement of OCD symptoms and as a result of this study, it has been reported that the pregnancy is associated with the beginning and/or exacerbation of OCD (13). In our study, it may not be appropriate to comment due to the small number of patients with schizophrenia and OCD.
When the trimesters in which the illness has begun were examined in our study, it was identified that the most of the patients with unipolar depression (51.1%) had become ill in the second trimester. However, in a study which evaluates the relapse rates and trimesters of women with depression during pregnancy, it has been shown that depression relapses mostly in the first trimester (51.2%) (11). In contrast to this study, our study demonstrated that risk of becoming ill was the highest in second trimester. This may be due to most of our patients have unplanned pregnancies and in accordance with this that they might not have any preperation period. Thus the drugs have been used until pregnancy and they stop using their medication as they learned they were pregnant. This may shift the onset of disorder to the second trimester.
In another study, it has been reported that most of relapses of bipolar disorder were in the first trimester during pregnancy (47.2%) (12). In our study, we detected that the most of the patients with bipolar disorder (45%) had become ill in the second trimester. This data do not support our study completely and our data shows that the second trimester has a higher risk for recurrence of bipolar disorder.
According to data in our study, manic episodes are more commonly seen than depressive or mixed episodes whether as a first episode or recurrence in bipolar disorder. Although there are not sufficient data for the episode subtypes of bipolar disorder during pregnancy, Viguera et al. (12) showed in a study that 74% of patients who relapsed during pregnancy had had depression or mixed episodes. On the contrary, our study showed that there were more manic episodes. Difference from the current literature may stem from the insufficient number of patients with bipolar disorder in our study.
Given complete response to treatment is considered to be CGI-S ≤2 after treatment, complete treatment response were obtained in the 89.4% of patients who received ECT. This ratio was 72% in those who did not receive ECT. This shows that ECT was more effective than pharmacological treatment in pregnancy.
In a review of studies published between 1942 and 1991, 300 patients, who underwent ECT during pregnancy were examined in terms of maternal and fetal complications and there were complications associated with ECT in 28 of these 300 cases (14). These complications have been reported to be temporary and benign fetal arrhythmias, light vaginal bleeding, abdominal pain and self-limiting uterine contractions (15). In our study, three patients were identified to have temporary uterine contractions. Given the available data in the literature, it has been remarked that ECT was an effective treatment for severe mental disorders during pregnancy and has low risk for the mother and the baby (14). Data of our study show that psychiatric patients could be treated safely and effectively with ECT during pregnancy.
In patients under treatment with SSRIs, SNRIs and/or benzodiazepines during pregnancy, preterm birth rate has been found to be significantly increased (16). In our study, none of 47 patients, whose birth information was available had a preterm birth. Our study was not compatible with the current literature.
Atypical antipsychotics are more frequently used in the treatment of both schizophrenia and bipolar disorder (17,18). Although in two studies which are prospective and retrospective, there were congenital defects caused by atypical antipsychotics in level of case reports, these cases had not directly been associated with the use of atypical antipsychotics (18-20). In our study, of 11 patients on antipsychotic treatment 9 were using atypical antipsychotics during pregnancy. No pathology was detected in infants of these patients.
The strength of our study comes from that it determined the trimester at which the psychiatric disorders are mostly seen, demonstrated that preterm birth is not associated with psychiatric treatment and it is the most extensive series of pregnant patients with psychiatric disorders in Turkey. Unavailability of some patients’ information and insufficient number of patients may be accounted for the limitations of our study.
Having a psychiatric disorder during pregnancy was found to be highest in the second trimester. Premature birth was not detected in any patients, whose birth information was available and it has been shown that the most important risk factor for psychiatric disorders in pregnancy was the history of having a prior psychiatric disorder.